RileyDMFT6104-11

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Week 11: Signature Assignment Danae Riley School of Social and Behavioral Sciences, Northcentral University MFT-6104 v2: Family Therapy with Children Dr. Chisato Hotta January 12, 2022

Anorexia Nervosa The child-centered problem I have chosen to discuss further as my Signature Assignment is Anorexia Nervosa. My rationale for choosing this diagnosis is that adolescence is the primary timeframe for this condition to begin presenting itself, and in recent years cases have been documented of children as young as 5 years old (Morris et al., 2022). Not only is the prevalence of this disorder most commonly presenting in this age group, but an emergency call for awareness and early intervention is necessary based on the alarming statistic of individuals with anorexia being 5 times more likely to die prematurely and 18 times more likely to die by suicide (Cleveland Clinic, 2021). Anorexia Nervosa is an eating disorder which involves the primary characteristics of distortions in thought processes regarding food or the image of one’s body in general, affecting an estimated 1% of the population (Eating Disorders, 2016). The American Psychiatric Association explains the DSM-5 diagnostic criteria is comprised of three key symptoms. The first symptom is the fear of and intentional limitation of food consumption in general, or restriction from specific types of food resulting in significant weight loss, putting them within a BMI range that is significantly lower than the healthy range. The second symptom is often referred to as “fat phobia,” meaning they have an intense & irrational fear of gaining weight or becoming fat despite their low BMI. The third symptom of Anorexia is severe distortion of one’s body shape and size, causing an inability for them to recognize how critical their condition may be. And the two additional characteristics of Anorexia which not all clients display, but that are quite common, are extreme levels of exercising and purging which may include vomiting or the use of laxatives. If a client exclusively restricts food and/or overly exercises for 3+ months, they are given a specifier of “Restricting type,” and if they exclusively binge-eat and purge for 3+ months they are given a specifier of “Binge-Eating/Purging Type” (American Psychiatric Association, 2013).

Case Study: Sam Amy (41) partner Vero (43) are concerned about their daughter Karly’s behavior and mood recently. Their initial call described Karly (15) as having drastically changed over the last year or so following her transition to high school. The family moved from a very small town in Avon, MN to San Diego, CA for Amy’s new job just a month before Karly’s freshman year. Karly seemed excited about the move originally, but a few months into the new school year, her mood seemed to shift a bit. Karly was always a bit “type A,” but she seemed overly concerned about her performance at school and became seemingly obsessive with her training to get on the cross-country team her sophomore year. The tryouts are in a couple of weeks and two days before Amy and Vero reached out to me, they received a call from the school letting them know that Karly had fainted in one of her classes. When they took her to the hospital to make sure she was ok, the doctor seemed alarmed at her BMI and decided to run some additional tests which determined that Karly was anemic. The doctor asked Karly about her eating habits and requested a physical examination which clearly showed indications of malnourishment likely being the cause of an eating disorder given that the test results did not come back with any other likely causes. Karly was very quiet and non-responsive to many of the questions the doctor was asking about her feeding habits, so it was recommended that the family be assessed by a Marital and Family Therapist to further determine an appropriate multi-disciplinary care plan. The doctor referred the family to my office as we regularly work with one another. Amy and Vero confessed that they had some concerns about Karly’s weight, but she was incredibly private, not allowing her body to be exposed much with her oversized clothing which was the trend with many kids now. They felt at times like they were walking on eggshells because she would snap at them constantly, so they just stopped asking personal questions and assumed this was just what it was like raising a teenager. Karly was gone so often with her early runs in the morning and weight training in the

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afternoon, and she took her lunch that was made for her, but they didn’t know if she had been eating it. They also recalled that dinners had been stressful with new dietary restrictions based on her training and often requests to just take her food to her room to study. They knew this would be a big transition for their entire family, but Amy and Vero are worried that this transition has severely impacted their daughter to a point where they have recently begun discussing Amy leaving her job to move the family back to Avon. They recalled one night a few months ago when Karly responded to their request for her to come to a friend’s birthday party with them versus doing her normal training by saying that she couldn’t miss it because she must keep up with all these fit, and beauty-focused people here. Amy and Vero’s marriage has been affected due to differences of opinion on the boundaries set for Karly and Amy’s job has required much more time and energy than originally expected, causing Vero to feel somewhat abandoned and guilty claiming fault for not catching these issues as the mom who is spending the most time with Karly currently. The family who used to be so close to one another is feeling like they don’t even know each other these days. Amy and Vero are committed to doing whatever they need to get their daughter healthy and expressed that they know they need to make some changes as well to improve their communication with one another and with Karly to bring their family closer again. Assessment During my initial assessment, I gave each member of the family an opportunity to vocalize their concerns and perspective without interruption or response from the others. I inquired about their individual feelings associated with their recent transition from Avon to San Diego and asked for specific details on the ways their lives had changed since moving. This information allowed me to identify some of the adverse patterns of behavior and communication that may be influencing the changes to their life since transitioning.

I requested that Karly take the SCOFF questionnaire which is a quick assessment tool to identify disordered patterns associated with eating disorders. The acronym SCOFF stands for sick, control, one stone, fat, food. The questions include, do you make yourself sick because you feel uncomfortably full, do you worry that you have lost control over how much you eat, have you recently lost over 14 pounds in a 3-month period, do you believe yourself to be fat when others say you are thin, and would you say food dominates your life? (Read, 2021). Instead of having Karly simply mark yes or no for each of these questions, I asked the questions openly to Karly, allowing her to respond with more open discussion. Given the clarity of there being an eating disorder already, these questions gave us a baseline for understanding some of the basic characteristics of her eating disorder while confirming the diagnosis with a more formal assessment procedure. I also had Karly take the eating disorder examination questionnaire (EDE- Q) to assess the frequency of disordered attitudes and behaviors over the last 28 days (Peterson et al., 2020). Knowing the level of commitment that Amy and Vero made to improving Karly’s mental and physical health, I recommended that we begin with an outpatient therapy approach to begin with, combining Psychoeducation, Family Based Therapy for the family system and Parental Group Therapy for Amy and Vero (Le et al., 2011). Though she had the fainting incident, none of her other medical tests indicated life threatening concerns at this time and based on my early assessment of the family system I am confident that they have the strengths necessary to overcome this challenge together without requiring an inpatient program. Allowing Karly to remain in her normal home during treatment will likely decrease further trauma of additional changes to her environment and may allow her to develop new perspectives and behavioral patterns associated with this new home of theirs (Le et al., 2011). The approach to care for Karly will be multi-faceted, relying on specialized providers for her primary care, nutrition, psychiatry, and psychotherapy. This approach will ensure that Karly’s

diagnosis is treated holistically from a bio-psycho-social perspective (Cleveland Clinic, 2021). My recommendation is that we begin with a schedule of one therapy session per week for the family. I will also be providing resources to Amy and Vero so they can connect with a local support group during this time for parents of children with eating disorders. I also have a nutritionist who I work closely with for all my clients with eating disorders who I consult with on to discuss any nutritional questions related to the development of a goal weight and plan for the increase of caloric intake Karly will need to re-gain her proper BMI (Reese, 2022). Intervention My initial intervention with the family began with Psychoeducation on what eating disorders are, how they often impact individuals and their families, and what the outcomes are if treatment is not committed to. A focus on the severity of this disorder’s progression is important for the entire family to sit with the feelings of discomfort and anxiety around the bleak outcomes of Karly continuing to go down this path (Le et al., 2011). With adolescents who still live with their parents, it is important for the family to understand the extensive involvement that will be required of the parents during the process of getting their child well (Laura et al., 2022). I also spent the first session describing to the family what Family Based Therapy is. Amy and Vero seemed to quickly connect to the understanding of a need in this system to change the patterns of negative and distorted thoughts leading to maladaptive and unhealthy behaviors to a holistically new way of thinking to challenge the system, and for Karly specifically to adapt to more healthy patterns moving forward. Karly was still quiet and seemingly frustrated within this first session which is to be expected, given that she does not believe her condition is as concerning as it is and that she will be unable to continue her training for tryouts coming up. I made sure during this session to vocalize my sympathy for how difficult this must be for her yet continued to encourage her participation in the process while she has so many people here who love her and

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want her to be able to return to the social and lively girl her parents described her to be (Le et al., 2011). I find it to be important for the family to understand the predictors of anorexia to help them see the impact of all aspects of biology, psychology, and society, allowing them to see the broad sweeping influences bringing us to this point to remove the common feelings of blame from the parents and the feelings of shame from the adolescent impacted. For example, Karly has always been a driven individual. Her parents referred to her as being “Type A” from a young age. These types of perfectionist and rigid ways of thinking may be early predictors for the development of an eating disorder (Cleveland Clinic, 2021). This in combination with a recent stressful life event like moving from a small farming town to a huge, heavily populated city full of “fit and beauty-focused” people caused Karly to grab at whatever control she could find, settling into the control of food consumption and exercise. On top of these two key factors, we must also look at the most common time for an eating disorder to begin being in adolescence and early adulthood, the ratio of women being 10 times more likely to develop an eating disorder and Karly being an athlete which carries and emphasis on thinness (American Psychiatric Association, 2013). The core approach to therapy with this family will be Family Based Therapy (FBT). Family Based Therapy is a solution-focused approach and is consistently the most effective evidence-based method to get adolescents back to good health utilizing the parents as key leaders of the refeeding efforts and partners in the rehabilitation of their child (Cleveland Clinic, 2021). Family Based Therapy has three phases including helping the parents work together toward the goal of ultimately reviving the healthy eating behaviors needed for their child to thrive, then helping the parents to slowly transition the control of making the right decisions about nutrition and energy intake back to their child, and finally intentionally identifying any developmental delays or problems that this diagnosis and symptomatology may have impacted (Le et al., 2011).

My recommendation was for the family to commit to weekly sessions for three months and then we would reassess at that point to determine if bi-weekly seems like an appropriate shift based on progression of therapy and healthy weight gain. The process of therapy moving forward will place Amy and Vero in the role of owning the plan for navigating the shifting of behaviors and will place the therapist in the role of supervising these changes and collaboratively strategizing with the parents on options to improve results (Le et al., 2011). The five tenants that guide FBT include the therapist and parents taking an agnostic view on the cause of anorexia, focusing on specifically when the restriction behaviors began and how they have developed, the therapist taking the consultative role and the parent being empowered to manage the process of recovery, and the separation of the disorder from the child which gives the family the opportunity to fight against the disorder versus their child (Le et al., 2011). One of the main concerns often addressed with the use of FBT is the immense amount of pressure and responsibility that the model places on the parents to provide care and consistency in the necessary changes to maladaptive patterns of behavior within the family system. The behaviorally-focused decisions about when she needs to eat, what kind of food and how much, and whether or not she can continue to workout tend to overwhelm parents. This sense of obligation can be daunting for given their common feelings of already having done something wrong causing this outcome of an eating disorder for their child, however, the method of FBT begins with the parental training to teach them new ways of thinking and in turn, new behavioral patterns to help their child and their entire family system to become healthy again (Le et al., 2011). The mental strength of the parents working within this model is often improved by their involvement in strengths-based parent support groups led by parents who had successful outcomes with their child recovering from an eating disorder. The exposure to other people with similar lived experiences allows parents to have an outlet to connect with a community that

understands what they are going through and who have success stories to share, shining a light on the anticipated outcomes for the family. I will strongly recommend that Amy and Vero attend bi-weekly group meetings during this period which I will connect them to, ensuring that the families that they are connecting to have used similar therapeutic methods with their children and adolescents (Laura, 2022). In combination with Family Based Therapy, another form of therapy that has shown to have successful outcomes for clients with eating disorders is Dialectical Behavioral Therapy (Peterson et al., 2020). Due to the high volume of clients we get in our therapy group who have eating disorders, I have partnered with a local eating disorder inpatient facility who offers adjunct sessions using DBT to clients seeking more robust care options while they work toward recovery. While FBT has highly effective outcomes in the restoration of healthy weight, this therapeutic model does not have a primary focus on helpful skills like how to handle stressful situations and how to identify your emotions and learn to regulate them more effectively (Peterson et al., 2020). Both skills will be imperative for Karly to master since one thing we know is that change is constant, and her ability to become more aware of the ways she is feeling, with the skills necessary to describe those feelings and work through them versus ignoring them and quite literally running them away. The group that Karly will attend will provide skill development targeting “increased mindfulness, distress tolerance, emotion regulation, and interpersonal effectiveness” (Peterson et al., 2020). This skills group is a 6-month commitment for clients, and typically within the first 2- 3 months they are able to see reductions in depressive symptoms often associated with anorexia (Peterson et al., 2020). This group will provide Karly with positive support to help her cope with the challenging and oftentimes angering process of FBT that she will be concurrently working through with her parents and myself (Peterson et al., 2020).

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After the first session, I called Karly’s doctor to discuss my assessment conclusions and my plan for intervention. He agreed with my approach, and I let him know I would follow up with him on any relevant updates along the way and would connect him with the nutritionist that we would be partnering with as a care team so that we could collaborate on progress and potential shifts needed throughout the treatment. I did mention to the doctor a potential recommendation of depression medication in the next few weeks based on treatment progress which he was also open to (Cleveland Clinic, 2021). I would like to see how Karly’s progress moves forward before moving toward medication, however this may be the best course of action for her as we work to regulate her current emotional reactivities. During the next few weeks, I will assess this need based on the use of the Child Depression Inventory – 2 which will examine Karly’s depressive symptomology over the prior 2 weeks, allowing me to track progress (Peterson et al., 2020). The main ethical concerns that I will keep attuned to with the treatment of an eating disorder like anorexia are autonomy due to the already strong skepticism that Karly has about the severity of her illness, and the life-threatening nature of her disorder in combination with potential comorbidities like anxiety and depression which we will continue to assess for throughout treatment. The responsibility being placed on the parents can feel scary but the preventative measures to keep Karly in her home versus potential trauma associated with inpatient care makes this path the best suited for her and her family at this time. We will monitor her health and continue to work on shifting her perspective on the severity of her illness to gain her trust and openness to change over time, allowing her to eventually become more autonomous with her decision making related to food and exercise (Le et al., 2011). Case Prognosis Moving into the next phases of intervention, I will continue to encourage the parents to make decisions about what nutritional foods would be good for their child and how much they

will recommend she eats of it in each setting. We will likely do exercises inclusive of food and requirements of Karly to eat the amounts that her parents are requesting of her. These phases often start with a lot of friction and resistance which will allow me to step in and coach Amy and Vero on some more effective methods to engaging with Karly and successfully gaining her agreement to eat the meal they have asked her to eat (Le et al., 2011). We will keep track of weight gains and losses over time to show the progression of recovery and remission if that’s the case and these regular check-ins will guide our conversations moving forward to discuss methods tried, what worked and did not work, and strategies to further progress positively moving forward (Le et al., 2011). Once Karly’s appropriate BMI is close to being met, we can transition into the process of giving her back some of the autonomy to make her own decisions about food again, and in this same time period we will encourage Karly to start running again. We will start small with snacks throughout the day and transition to her deciding on larger meals, and then to eating in new environments to eventually get back to full control being passed back to Karly (Le et al., 2011). Termination of Therapy Once Karly makes it to her healthy BMI, we will shift our focus to ensuring that Karly is living a fulfilling life, engaging in age-appropriate activities, and setting goals for her future (Le et al., 2011). We will move to monthly sessions, allowing the family to manage the recovery process together more consistently, and termination will consist of a final session providing psychoeducation on the possible signs of future relapse and how they may navigate those challenges (Le et al., 2011). Karly’s primary care doctor and I will continue to partner together throughout her treatment to ensure that if we do go the route of anti-depressants, her medication is regulated to her needs along the way. My recommendation to this client would be to come back for future sessions if relapse symptomology becomes persistent (Le et al., 2011).

References American Psychiatric Association (Ed.). (2013). Feeding and eating disorders. In Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: American Psychiatric Association. Cleveland Clinic (2021), Anorexia Nervosa. https://my.clevelandclinic.org/health/diseases/9794- anorexia-nervosa Eating Disorders. (2016). San Luis Obispo, CA: Classroom Productions. [Video File] Laura Grennan, Maria Nicula, Danielle Pellegrini, Kelly Giuliani, Erica Crews, Cheryl Webb, Maria-Rosa Gouveia, Techiya Loewen, & Jennifer Couturier. (2022). 'I’m not alone’: a qualitative report of experiences among parents of children with eating disorders attending virtual parent-led peer support groups. Journal of Eating Disorders , 10(1), 1– 15. https://doi.org/10.1186/s40337-022-00719-2 Le, G. D., & Lock, J. (Eds.). (2011). Eating disorders in children and adolescents : A clinical handbook . Guilford Publications. Morris, A., Elliott, E., & Madden, S. (2022). Early‐onset eating disorders in Australian children: A national surveillance study showing increased incidence. International Journal of Eating Disorders , 55(12), 1838–1842. https://doi.org/10.1002/eat.23794 Peterson, C. M., Van Diest, A. M. K., Mara, C. A., & Matthews, A. (2020). Dialectical behavioral therapy skills group as an adjunct to family-based therapy in adolescents with restrictive eating disorders. Eating Disorders , 28(1), 67–79. Read, A. K. (2021). The Implementation and Evaluation of the SCOFF (Sick, Control, One Stone, Fat, Food) Eating Disorder Screening Tool for Children and Adolescents. Pediatric Nursing, 47(3), 124–132.

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REESE, J. M. (2022). Assessment and treatment of eating disorders in adolescents. Contemporary Pediatrics , 39(4), 30–37. Williams, G. P., Williams, P., Desmarais, J., & Ravenscroft, K. (Eds.). (2003). Exploring eating disorders in adolescents : The generosity of acceptance. Taylor & Francis Group.

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